Understanding Alternate Work Schedules and Their Potential to Improve Work-Life Well-Being for Veterans Affairs Nurses

Abstract

Background:

The employee experience of clinical personnel, especially nurses, is increasingly vital for health care organizations and is now part of health care’s quintuple aim, which includes improving patient experience, population health, cost, and health equity. Nurse burnout and turnover intentions have heightened since the COVID-19 pandemic, with high workload and inadequate staffing as key organizational drivers. Flexible work schedules, such as 72/80 (where one works three 12-h shifts per week but receives the pay equivalent of 80 h), have been a longstanding countermeasure, but postpandemic data on their impact are limited.

Objective:

This national evaluation investigates the impact of the 72/80 work schedule on Veterans Health Administration (VHA) nurses. We hypothesized that nurses on a 72/80 schedule experience less burnout, higher job satisfaction, greater work engagement, and lower turnover intentions.

Design:

We conducted a web-based survey including self-reported 72/80 work status and employee experience measures, alongside existing administrative data on employee outcomes. We analyzed the data using Mann-Whitney U tests, mixed effects, and linear regression models.

Sample:

Eight thousand five hundred forty-five VHA nurses from 170 Veterans Affairs Medical Centers nationwide working in 24/7 bedded units completed the survey.

Results:

The 72/80 schedule was significantly associated with lower emotional exhaustion and depersonalization, and greater personal accomplishment. In addition, 72/80 status correlated with higher workplace engagement, job satisfaction, organizational satisfaction, and lower turnover intention.

Conclusions:

The 72/80 work schedule shows significant potential as a transformative workforce strategy, providing substantial benefits in recruitment, retention, and employee satisfaction.

The work life and well-being of clinical personnel have been a growing concern for health care organizations—indeed, improving workforce well-being is now considered part of health care’s quintuple aim for health care improvement alongside improving patient experience, population health, cost, and health equity.¹ Markers of clinician well-being include burnout, job satisfaction, and engagement. Burnout and job dissatisfaction are key precursors to employee turnover.² Burnout has been associated with lower quality of care,³ work engagement, organizational commitment, and job performance,³ as well as plans to reduce work hours or retire early.^4–6

As the nexus of much of the health care delivered in inpatient and emergency department (ED) settings, nurses are particularly vulnerable to the stressors that might lead to burnout, job dissatisfaction, and turnover. For example, burnout and turnover intentions among nurses have been increasingly salient since the onset of the COVID-19 pandemic, with levels as high as 62% among inpatient nurses according to the American Nurses Association.⁷ In a large survey of health workers in 124 organizations in the United States in fall 2020, nurses were the most likely to report intention to reduce work hours (33.7%) or to leave practice altogether within 2 years (40.0%) relative to physicians and other health care staff.⁸ In another survey of nurses in 1 state, 84% of practicing nurses reported high emotional exhaustion, 39% reported plans to leave their job in the following year, while 28% planned to reduce their work hours.⁹ Mandatory overtime was a key driver for nurses who left clinical practice.⁹

With heightened attention on burnout and turnover among inpatient nurses during and since the pandemic, the Veterans Health Administration (VHA) formed and implemented the Reduce Employee Burnout and Optimize Organizational Thriving (REBOOT) initiative.¹⁰ Charged with collecting and addressing work-life concerns from an increasingly taxed clinical workforce, REBOOT’s Task Force identified 6 drivers of burnout; chief among them were an unmanageable workload and lack of job control. Flexibility over their work schedule (eg, alternate work schedules, ability to take time off, and part-time work) was a chief concern among VHA employees.

Flexible work schedules are a common countermeasure for these concerns and have been available in the federal government system for decades.^11,12 Such schedules—which differ from the traditional 40-hour work week consisting of five 8-hour shifts per week—have shown evidence of effectiveness in various settings,^13–15 consistent with the tenets of the Job Demands-Resources (JD-R) model of job stress.¹⁶ For inpatient nurses, scheduling flexibilities can be particularly useful due to the 24-hour cycle of staffing needed in inpatient nursing wards. The 72/80 alternative work schedule (AWS),¹⁷ where nurses work six 12-hour shifts over a 2-week period but with pay and benefits equivalent to full-time work, lends itself especially well to this cycle. In the VHA, eligibility for this particular form of 12-hour shift is written into federal law.^17–19 All full-time or part-time registered nurses and nurse anesthetists under 7401(1) and 7405 appointed to title 38 positions are eligible to request a 72/80 work schedule, except for graduate nurse technicians and nurse technicians pending graduation. Individual facilities retain the local authority to grant said requests and implement this flexibility to best suit their needs.

Scheduling inpatient nurses in 12-hour shifts has grown popular in the private sector, though evidence of its effectiveness is mixed. For example, in their systematic review of nurse job satisfaction, Banakhar²⁰ observed 5 studies reporting greater nurse dissatisfaction with 12-hour shifts and 3 studies reporting greater satisfaction. In contrast, Stone et al²¹ found that, relative to 8-hour shifts, nurses on 12-hour shifts displayed greater job satisfaction, lower emotional exhaustion, and fewer unexpected absences and no difference in patient outcomes. More recent research²² reported that oncology nurses on 12-hour shifts expressed greater satisfaction and perceived benefits to quality and safety. However, the impact of these schedules on pay and benefits varies across hospitals; moreover, studies did not necessarily examine 12-hour shifts that also involved additional pay. The opportunity to examine the impact of VA’s approach with clear implications for scheduling, pay and benefits on a nationwide sample presents a unique opportunity, particularly in the post-COVID era where workload and workflows have shifted dramatically,²³ and where the importance of employee experience is increasingly valued.²¹

Some predictions on the benefits of 72/80 can be made based on theory—for example, the JD-R model would categorize 72/80 schedules as a resource to reduce job strain and would lead to reduced burnout and greater satisfaction.²⁴ Similarly, agency theory²⁵ would cast 72/80 as a signal to nurses that the organization cares about their well-being and thus could result in lower turnover. Nevertheless, more in-depth, empirical evidence and understanding are needed.

This paper presents findings from a quality improvement evaluation of the implementation of the 72/80 AWS. Evaluation data included a prospective nationwide survey of 16,170 Veterans Affairs (VA) nurses working in 24/7 bedded units with self-reports of 72/80 work status and employee experience measures, as well as existing administrative data on employee outcomes. Consistent with prior theory, we predicted that nurses on a 72/80 AWS would experience less burnout, higher job satisfaction, higher work engagement, and lower turnover intentions.

METHODS

Design

This policy evaluation was part of a larger, multipronged implementation of multiple interventions headed by the VHA REBOOT Task Force, a long-term initiative to address primary drivers of burnout through systemic changes. We conducted a cross-sectional observational evaluation consisting of web-based survey responses from 72/80 eligible nurses at VHA medical facilities nationwide, combined with existing facility characteristic data from administrative sources.

Intervention and Implementation Strategy

The rollout of the 72/80 schedule under the REBOOT initiative was a carefully phased effort designed to address burnout and improve workplace well-being. Beginning in August 2021 with the formation of the REBOOT Task Force, the initiative engaged VHA leaders, frontline staff, and unions to identify systemic issues contributing to burnout. By early 2022, focus groups with over 700 employees revealed critical workplace challenges, leading to the identification of 7 priority focus areas in May 2022, which were formally approved by the VHA Governance Board on June 23, 2022. One such area was maximizing workplace flexibilities, including the 72/80 AWS.

In February 2023, Workstream 4, VA’s ad hoc committee for implementing the 72/80 AWS, was formed, and by June 27, 2023, the 72/80 Alternate Work Schedule Blueprint²⁶ was released, providing detailed implementation guidance. This was followed by the October 6, 2023, dissemination of the Executive Decision Memo (EDM) entitled “Expanded Implementation of the 72/80 Alternative Work Schedule for Nurses,” which formally established the schedule as a governance-backed policy and best practice. To support adoption, national training webinars and consultations were conducted between September 2023 and March 2024, while discussions with the National Association of Government Employees (NAGE) Union on October 19, 2023, focused on workforce concerns and stakeholder support. The implementation process focused on maximizing the use of HR policies and flexibilities, with efforts to communicate and encourage their use to support recruitment, retention, and employee well-being. Figure 1 displays a timeline of all implementation activities.

FIGURE 1.

Timeline of implementation milestones for the 72/80 schedule.

Participants

We invited 64,447 registered nurses (RN) working at 24/7 bedded units (eg, medical, surgical, intensive care, ED) in 170 VA Medical Centers nationwide. Other types of nurses (eg, LVN, NA) and nurses working at 72/80 ineligible settings (whether by law or by nature of work, like outpatient clinics that are only open 8 ​​​​​​h/d) were excluded.

Procedure

Participant Pool Selection

We obtained lists of eligible nurses from administrative personnel records (see the Measures section). The lists were generated using the following inclusion criteria: full-time registered nurses with assignment codes associated with 24/7 bedded units. Part-time, intermittent, trainees, nonpay appointments, and noninpatient assignment codes were excluded.

Survey Development and Deployment

We developed a web-based survey (see the Measures section below for construct and item descriptions) deployed via Qualtrics, a VA-approved survey platform. Survey invitations were sent to nurses described in the participants section through e-mail, with an individualized link.

Measures

72/80 Eligibility

For purposes of this evaluation, we included a question at the beginning of the survey asking respondents whether they worked in a 24/7 bedded unit. Anyone who responded no to this question was deemed ineligible and exited from the survey.

Demographics

Participants reported their current nursing role, highest degree earned, nursing unit type, and particular VA facility in which they currently work.

72/80 Status

We asked respondents whether they were currently on the 72/80 AWS. For those who were on 72/80 AWS, we also asked whether they had been working 72/80 for >6 months or 6 months or longer.

Perceptions of the 72/80 Alternative Work Schedule

We asked participants to indicate what they found appealing and unappealing about 72/80 schedules; participants selected from prepopulated reasons and an optional free response.

Nurse Employee Experience

To allow the project to draw comparisons with broader VA employee outcomes, we used items from VA’s All-Employee Survey (AES) to measure 3 aspects of the nurse employee experience: burnout, job and organizational satisfaction, and work engagement. For burnout, we used 3 items adopted from the Maslach Burnout Inventory (MBI)²⁷—the gold standard for measuring burnout—used by the AES to measure emotional exhaustion, depersonalization, and personal accomplishment, respectively. Each item assessed for frequency of experience using a 7-point Likert response from 0=never to 6=every day.²⁸ To maintain consistency across the 3 burnout measures, we reverse-coded personal accomplishment, so lower scores reflect more favorable outcomes. Single-item burnout measures have been used in large-scale surveys of health providers and have shown concurrent validity with full MBI scale items.²⁸

In addition, we used single items to measure job satisfaction (Considering everything, how satisfied are you with your job?) and organizational satisfaction (Considering everything, how satisfied are you with your organization?), each measured on a 5-point Likert scale from 1=very dissatisfied to 5=very satisfied. We also included a measure of work engagement (This organization really inspires the very best in me in the way of job performance) measured on a 5-point Likert scale from 1=strongly disagree to 5=strongly agree, and an item measuring turnover intention (Are you considering leaving your job within the next year?) (yes/no). All satisfaction and engagement items included an additional choice, “not applicable,” which was treated as missing data. For all nurse employees' experience items, higher scores indicate higher levels of the relevant construct (eg, higher levels of satisfaction, which is desirable; higher levels of emotional exhaustion, which is undesirable; etc.).

Data Analysis

We downloaded survey responses from Qualtrics and conducted quality checks to ensure the analytic dataset consisted of valid responses. We calculated descriptive statistics to examine the characteristics of our survey respondents and used a combination of descriptive and inferential statistics to evaluate workforce outcomes associated with the 72/80 schedule. We calculated summary statistics to describe key metrics, including burnout, satisfaction, providing an overview of trends across groups and timeframes. Comparative analyses included nonparametric statistical tests, like the Mann-Whitney U test, to assess significant differences between 72/80 and non-72/80 along the aforementioned workforce outcomes. Because offering 72/80 schedules is fundamentally an administrative decision made by the director of a facility and may be indicative of broader facility-level organizational culture driving employee experience measures, we considered conducting multilevel modeling to control for facility-level effects of having 72–80 scheduling at the respondent’s facility. However, modeling results suggested that linear models were the most appropriate for our data.

Accounting for Facility Effects

Understanding that individuals from the same facility are often more like each other than those from different facilities, we conducted post-hoc analyses to investigate the effect of 72/80 status and facility-level mean burnout scores on individual nurses’ burnout levels, measured by emotional exhaustion, depersonalization, and personal achievement. We began by calculating intraclass correlation coefficients (ICC) to determine whether using mixed-effects or linear regression models was most appropriate. Mixed-effects models were not warranted for all outcome measures due to low ICC values (emotional exhaustion=0.03; depersonalization=0.06; and personal achievement=0.01), indicating little variance at the higher level and, therefore, random effects are not necessary. Consequently, simpler ordinary least squares (OLS) linear regression models were conducted, examining the effects of AWS and facility-level mean burnout scores while accounting for education and unit type.

RESULTS

Participant Response

Sixteen thousand one hundred seventy registered nurses stationed at 170 VA Medical Centers and their satellite locations from all 18 Veterans Integrated Services Networks (VISNs) responded to our survey (25% response rate). Of those, 13,913 submitted complete surveys (21.6%); of the completed surveys, 5365 respondents were from an ineligible nursing unit type (eg, 39% of completed surveys), resulting in a total of 8548 complete, valid surveys (13.3% completion rate). Table 1 summarizes the characteristics of survey respondents. Our survey was initially intended for RNs, but at the time the survey was collected, we did not have a reliable method of identifying a true denominator, as departmental assignment codes in our available data source were in the process of being recategorized by VA human resources. Consequently, we opted to be overly inclusive in our invitation to participate. We then included a filtering question at the survey’s beginning, asking to ensure only nurses working in 24/7 bedded units (ie, those whose working conditions lent themselves best to a 72/80 schedule) completed our survey. We inadvertently received responses from a small percentage of NPs and other nursing roles. Therefore, for the purposes of this work, we only include RNs in our final sample (n=8291) (see chart, Supplemental Digital Content 1, for survey participants, http://links.lww.com/MLR/D57).

TABLE 1.

Survey Participant Characteristics

Characteristic	All respondents (N=8548) [n (%)]	RNs only (N=8291) [n (%)]
Current nursing role
RNs	8291 (97.0)	8291 (100)
Nurse practitioners	231 (2.7)	0
Clinical nurse specialists	14 (0.2)	0
Certified registered nurse anesthetists	1 (0)	0
Other	11 (0.1)	0
Highest nursing degree attained
Associates	1458 (17.1)	1458 (17.6)
Bachelors	5422 (63.4)	5418 (65.3)
Master’s	1399 (16.4)	1210 (14.6)
Other	242 (2.8)	188 (2.2)
PhD	27 (0.3)	17 (0.2)
Primary clinical assignment
24/7 acute care bedded unit (eg, medical/surgical, ICU, acute MH, PACU)	5716 (66.9)	5578 (67.3)
24/7 continuing care bedded unit (eg, CLC, long-term MH unit)	1639 (19.2)	1564 (18.9)
Emergency department	1193 (13.9)	1149 (13.9)

CLC indicates community living center; ICU, intensive care unit; MH, mental health; PACU, post-anesthesia care unit; RN, registered nurse.

Nurse Employee Experience by 72/80 Status and Duration

We expected that nurses on a 72/80 AWS experience less burnout, higher job satisfaction, higher work engagement, and lower turnover intentions, even after controlling for facility-level nurse employee scores on each measure. As shown in Table 2, nurses on 72/80 AWS reported significantly lower emotional exhaustion and depersonalization, and higher personal accomplishment, job satisfaction, organizational satisfaction, and work engagement ratings than their counterparts (those not on 72/80 AWS). To account for the potential effects of a “honeymoon period” (period during early phase of implementation where an intervention enjoys greater popularity and fades over time), we compared responses from nurses who had been on a 72/80 AWS for <6 months (n=359) to those who had been on said schedule for 6 months or longer (n=980). We observed no significant differences in any of our outcomes between these 2 groups.

TABLE 2.

Mann-Whitney U Comparison of Workforce Outcomes by 72/80 Alternative Work Schedule Status and by Duration of Participation, Among 72/80 Alternative Work Schedule Participants

	72/80 AWS status			Duration of participation in 72/80 AWS
Workforce outcome	On 72/80 AWS (N=1823)	Not on 72/80 AWS (N=5494)	P	<6 mo (N=359)	≥6 mo (N=980)	P
Emotional exhaustion	2.56 (1.8)	3.82 (1.7)	<0.0001	2.27 (1.7)	2.18 (1.6)	0.4172
Depersonalization	2.19 (1.8)	3.44 (2.1)	<0.0001	1.94 (1.9)	1.82 (1.8)	0.3388
Personal achievement	1.90 (1.7)	3.44 (1.7)	<0.0001	1.97 (1.7)	1.82 (1.7)	0.1211
Satisfaction	3.59 (1.1)	3.27 (1.1)	<0.0001	3.70 (1.0)	3.68 (1.1)	0.8242
Organizational satisfaction	4.07 (0.9)	3.62 (1.0)	<0.0001	4.19 (0.9)	4.18 (1.1)	0.8058
Work engagement	3.65 (1.1)	3.22 (1.1)	<0.0001	3.8 (1.1)	3.77 (1.1)	0.9182

Values are reported as mean (standard deviation).

AWS indicates alternative work schedule.

Turnover Intention by 72/80 Status

Nurses on the 72/80 schedule were significantly less likely to consider leaving their jobs compared with those on traditional schedules. Twenty-eight percent of 72/80 nurses reported intentions to leave (with the remaining 72% of 72/80 respondents reporting no intentions to leave), compared with 44% of non-72/80 nurses who are considering leaving (with the remaining 56% of non-72/80 respondents reporting no intention to leave).

Perceptions of 72/80 Alternate Work Schedules

Nurses identified several appealing aspects of the 72/80 AWS (Fig. 2). The most frequently mentioned benefit was improved work-life balance, which was cited by 93.67% of nurses (n=8007). This was closely followed by reduced burnout (91.35%, n=7809) and increased flexibility for family needs (88.61%, n=7574). Additional benefits included enhanced morale (79.67%, n=6810) and extra days off (79.28%, n=6777).

FIGURE 2.

Respondent perceived the benefits and drawbacks of the 72/80 AWS. AWS indicates alternative work schedule.

Despite its reported benefits, nurses also reported various disadvantages to the 72/80 AWS. The most cited drawback was the loss of holiday leave (34.49%, n=2948), as nurses on 72/80—unlike other compressed work schedules—are not entitled to an in-lieu-of day when a holiday falls on their day off. This concern was followed by fear of losing overtime/compensation time (16.69%, n=1427). Other concerns included the physical and mental toll of 12-hour shifts (10.10%, n=863) and potential interference with work-life balance (9.73%, n=832).

Accounting for Facility Effects

For all models, we included corresponding facility-level burnout scores of each outcome as a confounding variable and education and unit type as covariates. Because we included facility-level AES data, we only included facilities with at least 20 individuals (ie, 109 facilities), bringing our final sample for the OLS analyses to 7526. OLS modeling results (Table 3) revealed that 72/80 nurses (M=2.56, SD=1.77) reported significantly lower emotional exhaustion scores than non-72/80 nurses (M=3.82, SD=1.68) even when controlling for facility-level emotional exhaustion, b ₁=−1.32, 95% CI [−1.4, −1.2], F(1, 7353)=819.41, P<0.001, η²=0.09, η² _partial=0.09. Similarly, we found 72/80 nurses (M=2.19, SD=1.98) reported significantly lower depersonalization scores than non-72/80 nurses (M=3.44, SD=2.05) even when controlling for facility-level depersonalization, b ₁=−1.34, 95% CI [−1.5, −1.2], F(1, 7353)=595.36, P<0.001, η²=0.07, η² _partial=0.07. Finally, our OLS results indicated 72/80 nurses (M=1.9, SD=1.74) also reported significantly better (ie, lower scores, which reflect a more desirable outcome because this measure was reverse coded) personal achievement scores than non-72/80 nurses (M=2.14, SD=1.71) even when controlling for facility-level personal achievement, b ₁=−0.22, 95% CI [−0.3, −0.1], F(1, 7353)=24.31, P<0.001, η²=0.00, η² _partial=0.00.

TABLE 3.

Ordinary Least Squares Regression Models Predicting Individual Burnout Dimensions on an Alternate Working Schedule

	Coefficient estimate	95% CI	F	η2
Emotional exhaustion	−1.32	−1.4, −1.2	819.41*	0.09
Depersonalization	−1.34	−1.5, −1.2	595.36*	0.07
Personal achievement	−0.22	−0.3, −0.1	24.31	0.00

CI indicates confidence interval.

^* The significance is at P-value <0.001.

DISCUSSION

In this paper, we report findings from a quality improvement evaluation examining the relationship between participating in a 72/80 AWS and workforce outcomes among a sample of 16,170 VA nurses in 24/7 bedded units. As predicted, 72/80 status was associated with positive employee experience outcomes. For burnout, 72/80 was strongly associated with less emotional exhaustion and depersonalization and greater personal accomplishment. Likewise, 72/80 status was also associated with higher workplace engagement, job satisfaction, and organizational satisfaction, as well as lower turnover intention. Further, the sustainment of these results in the secondary analyses despite the presence of significant facility-level effects lends confidence that the benefits of 72/80 AWS remain even in the presence of other facility or unit-level factors that may impact that outcome. It appears that the impact of 72/80 AWS contributes over and above other policies at a facility that may also improve nurse employee experience.

Our findings are consistent with recent meta-analyses highlighting the effectiveness of organization-focused interventions targeting physician burnout.^29,30 Panagioti et al³⁰ included only controlled studies and found that organization-focused interventions tended to focus on scheduling and other methods to decrease workload. Compared with physician-focused interventions, the pooled effects for organizational interventions were significantly larger, even though organizational studies were rare.³⁰

Our analyses comparing newly participating 72/80 nurses to nurses participating for a longer duration (less vs. <6 mo) indicated no significant differences between short or long tenure on 72/80. Because VA’s concerted effort to support and promote 72/80 AWS is relatively new, we set the cut-off for short-term implementation at 6 months. Realistically, even 6–12 months on a work schedule is a relatively short period. Future work should consider differences in outcomes for staff on modified schedules for at least a year or longer to test for the presence of a washout effect.

Given the potential for 72/80 AWS to reduce the need for overtime (ie, shifts are already 12 h), future work should examine the role of 72/80 on other nurse and organizational outcomes. For instance, frequent mandatory overtime has been cited as a factor for nurses leaving clinical practice.⁹ Although our study included turnover intentions, actual turnover after initiating scheduling flexibilities is another important outcome to document.

Limitations

Although this study explores nurse employee experience factors that are expected to impact individual performance and unit functioning, due to existing data source limitations, we were not able to evaluate the impact of 72/80 AWS on patient or unit-level outcomes. For instance, the reduction in shift hand-offs in a 24-hour period from 3 (8-h shifts) to 2 (12-h shifts) is thought to potentially improve continuity of care for patients as well as decrease errors from shift change.²¹ This is an important research area that requires further examination. The study only examined 1 AWS, particularly 72/80, which typically applies to 24/7 bedded units and within VHA, only applies to RNs, by legislative authority. Future work should examine other forms of AWS that accommodate a larger variety of work units, such as four 10-hour shifts in a 40-hour week (4/40 schedule), and flexible time to work a 40-hour week (flex time), to accommodate the needs of other clinical professionals.

The absence of a standardized, organization-wide criterion for defining “operationally eligible 72/80” nurses created challenges in calculating accurate adoption rates. Although all RNs are theoretically eligible to request a 72/80 schedule, practical eligibility depends on the work setting. For example, nurses in outpatient settings—which normally are open 8 hours per weekday—are unlikely to benefit from this schedule. Although operational partners provided lists, ∼25% of survey respondents were misclassified as ineligible, undermining data accuracy and comparability.

CONCLUSIONS/FUTURE DIRECTIONS

The 72/80 schedule demonstrates significant potential as a transformative workforce strategy, offering substantial benefits in recruitment, retention, and employee satisfaction. Nevertheless, questions remain regarding whether these improvements are sustained over longer follow-up. Further, although our study included turnover intentions, actual turnover after initiating scheduling flexibilities is another important outcome to document. By leveraging these findings, the VHA can refine its implementation strategies and create a more resilient and engaged health care system.